Transverse myelitis

Background

Inflammatory disorder that involves a complete transverse section of the spinal cord
- Results from viral infection (30% of cases), postvaccination or as part of MS, SLE, or cancer
May present exactly like a compressive lesion of the spinal cord
Usually thoracic origin, rarely cervical spine

Rapidly progressive paraplegia (as little as 4 hours), but may progress over days-weeks
Neck or back pain + neuro complaints:
- Bilateral motor, sensory (burning or tingling pain), and autonomic disturbances
- Fecal/urinary retention and incontinence

Neuromuscular weakness
- Upper motor neuron:
  - CVA
  - Hemorrhagic stroke
  - Multiple sclerosis
  - Amyotrophic Lateral Sclerosis (ALS) (UMN & LMN)
- Lower motor neuron:
  - Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
  - Infection (Epidural abscess)
  - Infarction/ischemia
  - Trauma (Spinal Cord Syndromes)
  - Inflammation (Transverse Myelitis)
  - Degenerative (Spinal muscular atrophy)
  - Tumor
- Peripheral nerve disease:
  - Guillain-Barre syndrome
  - Toxins (Ciguatera)
  - Tick paralysis
  - Diabetic peripheral neuropathy
- NMJ disease:
- Muscle disease:
  - Rhabdomyolysis
  - Dermatomyositis
  - Polymyositis
  - Alcoholic myopathy
Non-neuromuscular weakness
- Can't miss diagnoses:
  - ACS
  - Arrhythmia/Syncope
  - Severe infection/Sepsis
  - Hypoglycemia
  - Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
    - Hypokalemic periodic paralysis
    - Thyrotoxic periodic paralysis
  - Respiratory failure
- Emergent Diagnoses:
  - Symptomatic Anemia
  - Severe dehydration
  - Hypothyroidism
  - Polypharmacy
  - Malignancy
- Other causes of weakness and paralysis
  - Acute intermittent porphyria (ascending weakness)

Neurologic findings that are consistent with epidural compression but normal MRI
Must rule-out compressive lesion of the cord
MRI
- May show cord swelling
- Hyperintense lesion on T2 weighted images
LP
- Contains monocytes, protein content is slightly increased, and IgG index is elevated[1]

Foley for bladder decompression
Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for aortic dissection
Neurological consultation
Admit for corticosteroids and plasma exchange
- High dose steroid regimen, such as methylprednisolone 1 gram daily or dexamethasone 200 mg daily
The more rapid the progression is, the worse the prognosis

Perron AD, Huff JS. “Spinal Cord Disorders,” in Rosen’s Emergency Medicine Concepts and Clinical Practice, edited by Marx JA, Hockberger RS, Walls RM, et al., 1389-1395. Philadelphia: Mosby, 2010.

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